Essential Component 6
There are seamless transitions across all care settings

Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

Why is this an Essential Component?

Evidence for inclusion

As people approach and reach the end of life they, their families and carers are required to navigate increasingly complicated care systems to address their needs.

Current patient journeys are often poorly coordinated and this is particularly true for people with advanced chronic disease who have multiple comorbidities and a much slower and more unpredictable trajectory of functional decline (ACI, 2015). The needs of people, their families and carers during their end of life journey vary over time and care setting, meaning services need to be responsive, coordinated and flexible in meeting these changing needs.

It has been demonstrated that navigation support and or care coordination improves clinical outcomes and the experience and satisfaction of patients, families and carers.

A strong collaborative approach to care has been shown to not only increase patient satisfaction, patient care quality and optimise the use of finite resources, but is also likely to reduce errors, limit gaps in care and lessen unnecessary treatments and hospitalisations (NSW Health, 2019; Palliative Care Australia, 2018).

Provision of safe healthcare requires a synergistic approach with an emphasis on shared case management, effective communication, data sharing and teamwork between multidisciplinary professionals across all healthcare settings. A lack of continuous collaborative care is a contributing factor in adverse patient events (NSQHS, 2017).

Intended beneficial outcomes

  • People are able to receive care aligned with their goals as they transition between settings of care (i.e. hospital, home, aged care).
  • Care is well coordinated and support is provided to patients, families and carers to assist in navigating health and community care systems.
  • Care providers across all settings understand their unique roles and are skilled in providing care to people as they approach and reach the end of their lives.
  • Clinical handover of care is optimal and supported by clear communication and clinical tools.
  • Changes in care requirements are identified and responded to appropriately.
  • Formalised referral and access arrangements support transitions of care.
  • Clinical information to support seamless care is available at the point of care.
  • Transfer of care occurs in consultation with patients, families, carers and care providers across all settings.
Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

What tools/resources could support the implementation of this component?

The Agency for Clinical Innovation commissioned CareSearch (Palliative and Supportive Services, Flinders University) to identify local, national and international tools or resources that can potentially be used to implement each of the ten (10) Essential Components of Care within the Blueprint.

To be included, tools and resources were required to be in English, be applicable to the Australian context and be supported by evidence (such as published validation studies, clinical guidelines representing expert consensus, or advice from expert clinicians who were consulted).

The set of tools and resources provided is not intended to be exhaustive, nor is any one tool specifically recommended. Click here for more information on the methodology adopted by CareSearch in identifying these tools and resources.

Core Palliative Care Tools

Core Resources

Additional Resources for Specific Populations

Core Palliative Care Resources